Mapping evidence-based guidelines to standardized nursing terminologies

SNOMED-CT as a standardized language system model for nursing: an integrative review

OBJECTIVE

To describe the use of the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) as a model for interoperability of the nursing terminology in the national and international contexts.

METHODS

This is an integrative literature review according to Cooper, which searched for articles in Portuguese, English and Spanish, published between September 2011 and November 2018 in the BVS, PubMed, SCOPUS, CINAHL, EMBASE, and Web of Science databases, ending in a sample of 15 articles.

RESULTS

The SNOMED-CT is a multi-professional nomenclature used by nursing in different care contexts, being associated with other standardized languages of the discipline, such as ICNP®, NANDA-I, and the Omaha System.

CONCLUSION

This review has shown that the use of SNOMED- CT is incipient in the national context, justifying the need to develop studies aimed at mapping the interoperability of existing systems of standardized language, especially NANDA-I, ICNP and Omaha System, in order to adapt the implementation of SNOMED-CT.

Taxonomic Triangulation of Care in Healthcare Protocols: Mapping of Diagnostic Knowledge From Standardized Language

Taxonomic triangulation is a data mining technique for the management of care knowledge. This technique uses standardized languages, such as North American Nursing Diagnosis Association International, Nursing Outcomes Classification, and Nursing Interventions Classification, as well as logic. Its purpose is to find patterns in the data and identify care diagnoses. Triangulation can be applied to databases (clinical records) or to bibliographic sources (eg, protocols). The objective of this study is to identify the care diagnoses implicit in the nursing care protocols of the Community of Madrid. The method followed has three phases: knowledge extraction for mapping of variables, linking to diagnoses, and triangulation with analysis. The study analyzes six protocols, and 344 variables (167 assessment, 29 planning, and 148 intervention) and 6118 links have been extracted. Triangulation identified 165 NANDA diagnoses (68.48%), and only 25 labels were not revealed through this process. As a limitation, the results depend on the knowledge presented in protocols and change with language editions. Some labels included in the sample are recent and are not included in the links with nursing outcomes classification and nursing interventions classification. In conclusion, taxonomic triangulation makes it possible to manage knowledge, discover data patterns, and represent care situations.

Mapping Perinatal Nursing Process Measurement Concepts to Standard Terminologies

The use of standard terminologies is an essential component for using data to inform practice and conduct research; perinatal nursing data standardization is needed. This study explored whether 76 distinct process elements important for perinatal nursing were present in four American Nurses Association-recognized standard terminologies. The 76 process elements were taken from a valid paper-based perinatal nursing process measurement tool. Using terminology-supported browsers, the elements were manually mapped to the selected terminologies by the researcher. A five-member expert panel validated 100% of the mapping findings. The majority of the process elements (n = 63, 83%) were present in SNOMED-CT, 28% (n = 21) in LOINC, 34% (n = 26) in ICNP, and 15% (n = 11) in CCC. SNOMED-CT and LOINC are terminologies currently recommended for use to facilitate interoperability in the capture of assessment and problem data in certified electronic medical records. Study results suggest that SNOMED-CT and LOINC contain perinatal nursing process elements and are useful standard terminologies to support perinatal nursing practice in electronic health records. Terminology mapping is the first step toward incorporating traditional paper-based tools into electronic systems.